<h1>
    Demande  de renseignements</h1>
<table width="100%" border="0">
  <script type="text/javascript" language="JavaScript" src="js/veriform.js"></script>
  <tr>
    <td width="80%"><form action="cible.php" onsubmit="return verifFormAbonnement(this)"  method="post">
      	Civilit&eacute;:&nbsp;&nbsp;&nbsp;    
        <select name="civilite" id="select">
           <option>M.</option>
           <option>Mme</option>
        </select>
        
<br />
        Nom :&nbsp;&nbsp;&nbsp;&nbsp;      
        <input type="text" name="nom" onblur="verifText(this)" />
        <br />
        Pr&eacute;nom :
        <input type="text" name="prenom" onblur="verifText(this)" />
        <br />
        Date de naissance:
        <input type="text" name="date_jour" size="2" onblur="verifJour(this)" />
   
        <select name="date_mois" id="select2">
          <option>Janvier</option>
          <option>F&eacute;vrier</option>
          <option>Mars</option>
          <option>Avril</option>
          <option>Mai</option>
          <option>Juin</option>
          <option>Juillet</option>
          <option>Ao&ucirc;t</option>
          <option>Septembre</option>
          <option>Octobre</option>
          <option>Novembre</option>
          <option>D&eacute;cembre</option>
        </select>
        <input type="text" name="date_an" size="8"onblur="verifAn(this)" />
        (JJ/MM/AAAA)<br />
         Adresse:&nbsp; &nbsp; &nbsp; &nbsp; 
        <input type="text" name="adresse" size=40 onblur="verifEmpty(this)" />
         <br />
         Code postal :
        <input type="text" name="cp" onblur="verifCP(this)" />
         <br />
          T&eacute;l&eacute;phone:&nbsp; &nbsp; 
        <input type="text" name="telephone" onblur="verifTel(this)" />
        <br />
        E-mail :&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 
        <input type="text" name="email" size="30" onblur="verifMail(this)" />
        <br />
        Soci&eacute;t&eacute; :&nbsp; &nbsp; &nbsp; &nbsp; 
        <input type="text" name="societe" onblur="verifText(this)" />
        <br />
        Commentaire:
        <label>
        <textarea name="commentaire" id="textarea" cols="45" rows="5"></textarea>
        </label>
        <br />
        <br />
        <input type="submit" value="Valider" />
      </p>
      </fieldset>
      </div>
      <p>&nbsp;</p>
    </form></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
</table>
<p>&nbsp;</p>
